NHSN Dialysis Event Surveillance Protocol

January 2022

Dialysis Event Surveillance Protocol

Table of Contents

Dialysis Event Surveillance Protocol ............................................................................................................................... 1 Introduction............................................................................................................................................................................... 2 Reporting Instructions .......................................................................................................................................................... 2

Complete a Survey Annually .......................................................................................................................................... 2 Complete Monthly Reporting Plans ............................................................................................................................ 2 Report Denominator Data Monthly............................................................................................................................. 3 Report Numerator Data Monthly ................................................................................................................................. 3 Dialysis Event Surveillance Overview............................................................................................................................. 4 Event Definitions and Key Terms ................................................................................................................................ 5 Measure Definitions........................................................................................................................................................... 8 Vascular Access Types ...................................................................................................................................................... 8 Data Quality ............................................................................................................................................................................... 9 Data Analyses ............................................................................................................................................................................ 9 Additional Resources ...........................................................................................................................................................10

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Dialysis Event Surveillance Protocol

Introduction

More than 425,000 patients are treated with maintenance hemodialysis in the United States. Hemodialysis patients require a vascular access, which can be a catheter, or a graft or an enlarged blood vessel that can be punctured to remove and replace blood. Bloodstream infections and localized infections of the vascular access site cause substantial morbidity and mortality in hemodialysis patients. Hemodialysis vascular access types, in order of increasing risk of infection, include arteriovenous fistulas created from the patient's own blood vessels; arteriovenous grafts typically constructed from synthetic materials; tunneled central lines; and non-tunneled central lines. Other access devices, such as cathetergraft hybrid devices, also exist. Because of frequent hospitalizations and receipt of antimicrobial drugs, hemodialysis patients are also at high risk for infection with antimicrobial-resistant bacteria. Measuring and tracking rates of infection and utilizing this information is an important part of prevention. Infection prevention information is located at:

Reporting Instructions

Location: NHSN requires that facilities map each patient care area in their facility to one or more locations, as defined by NHSN, in order to report surveillance data collected from these areas. For the Dialysis Event Module, facilities should choose one of the following locations to report their surveillance data:

? Outpatient Hemodialysis Clinic (OUT: NONACUTE: CLINIC: DIAL) ? Outpatient Hemodialysis Clinic-Acute Kidney Injury (OUT: NONACUTE: CLINIC: DIAL_AKI)

NHSN forms and/or the definitions in this protocol should be used to collect required data. Each form has a corresponding table of instructions (TOI) that can be located on the NHSN Dialysis website.

Complete a Survey Annually

Upon enrollment and annually thereafter, complete the Outpatient Dialysis Center Practices Survey (CDC 57.500). After enrollment, the data for the dialysis survey should be collected and reported in February.

Complete Monthly Reporting Plans

The Monthly Reporting Plan (CDC 57.501) is used by NHSN facilities to inform CDC that they are following the NHSN surveillance protocol, in its entirety, for each data type selected on the plan. A Monthly Reporting Plan must be completed before data can be entered into NHSN for that month.

? To indicate the facility is reporting in accordance with this protocol, save a Monthly Reporting Plan with the "DE" checkbox selected for the `outpatient hemodialysis clinic' and `outpatient hemodialysis clinic-AKI' locations, under the Events section, for each month that the facility is participating in Dialysis Event Surveillance.

If your facility is not following any protocols for the Dialysis Component modules for a particular month (e.g., the facility was closed), select "Not Participating in NHSN this Month."

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Dialysis Event Surveillance Protocol

Report Denominator Data Monthly

The denominators are counts of patients by vascular access type used to estimate the number of patient-months considered at risk for dialysis events. To report denominator data, each month, report the number of hemodialysis outpatients and their hemodialysis vascular access type who received hemodialysis at the center during the first two working days of the month on the Denominators for Dialysis Event Surveillance-Census Form (CDC 57.503).

Report all hemodialysis outpatients, including transient patients. Exclude non-hemodialysis patients and exclude inpatients. Report denominator data each month, regardless of whether any dialysis events occur. Count each patient only once; if a patient has multiple vascular accesses, record that patient once, reporting only their vascular access type with the highest risk of infection (note: this might not be the vascular access currently in use for dialysis). Definitions of each type of vascular access lines can be found under the Dialysis Event Surveillance section.

LOWER INFECTION

RISK

Fistulas

Grafts

Other Vascular Access Devices

Tunneled Central Lines

Non-tunneled Central Lines

HIGHER INFECTION RISK

The Tables of Instructions (TIOs), located on the NHSN Dialysis website, provide an explanation of each field of the Denominators for Dialysis Event Surveillance-Census Form.

Working Days: The first two "working days" of the month should provide the opportunity to capture all regularly scheduled shifts and patients.

? For example, if a facility dialyzes patients 6 days a week, Monday through Saturday, and the first

day of the month falls on a Sunday, then Monday and Tuesday would be the first two working

days of the month for that facility.

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

1

2

3

4

5

6

7

Facility Working Working

closed

day 1

day 2

? For facilities that provide nocturnal hemodialysis, working days should include nocturnal hemodialysis patients.

? Working days are shift/schedule dependent ? the actual patient census is not a criterion for determining a working day.

? If the facility was closed the entire month, do not complete a denominator form.

Report Numerator Data Monthly

The numerators are the number of dialysis events that occur during a defined time period. To report numerator data, complete one Dialysis Event form (CDC 57.502) per occurrence of event(s) among any patients who received hemodialysis at the facility during that month. If there are no dialysis events to report, access that month's denominator form to "Report No Events."

Report Events: Any patient who receives outpatient hemodialysis treatment at your facility is monitored for dialysis events, even if they were not counted on the denominator form. Include transient patients at

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Dialysis Event Surveillance Protocol

your facility who have a dialysis event. Complete a Dialysis Surveillance Event form if a hemodialysis outpatient has one or more of the following:

Positive blood culture IV antimicrobial start Pus, redness, or increased swelling at the vascular access site

Multiple Dialysis Events: If multiple dialysis events occur together, for a single patient, the events should be reported on the same Dialysis Event form. For example, if a patient has a positive blood culture and begins IV antimicrobials, these two events are recorded together on one form. When reporting multiple dialysis events together, the "date of event" is always the date that the first event occurred. Do not report unrelated dialysis events on the same form. Events are considered related if fewer than 21 days have passed since the last reported event of the same type. Refer to an explanation of the "21-day rule".

Event Type

IV antimicrobial start

Positive blood culture Pus, redness or increased swelling at vascular access site Combination

Date of Event Criterion Date of first outpatient dose of an antimicrobial course Date of specimen collection

Date of onset

Earliest date of the three types

Report No Events: Each dialysis event type needs to be accounted for every month. Either (a) the event type is reported on one or more Dialysis Event forms, or (b) the "report no events" box for that event type is checked on the Denominators for Dialysis Event Surveillance-Census Form to confirm that no events of that type occurred during the month.

Dialysis Event Surveillance Overview

Each month, facilities report the number of hemodialysis outpatients who were dialyzed in the facility on the first two working days of the month, using the Denominators for Dialysis Event Surveillance form. This count is used to estimate the number of patient-months for which there is risk of healthcare-associated infection. Throughout the entire month, any and all outpatients who receive hemodialysis at the facility are monitored for three National Healthcare Safety Network (NHSN)defined dialysis events, which are: IV antimicrobial starts, positive blood cultures, and evidence of local access site infection. Facilities use a Dialysis Event form to report the details of each dialysis event that occurred among patients. Before data can be reported, facilities must indicate that they are reporting according to this protocol by saving a Monthly Reporting Plan and selecting "DE." Completion of an Outpatient Dialysis Center Practices Survey is required annually.

Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be attached to or affiliated with a hospital but should serve hemodialysis outpatients. If other patients (e.g., inpatients, peritoneal dialysis patients) are present, exclude them from Dialysis Event numerator and denominator reporting.

Population: In-Center Hemodialysis outpatients. The facility who is currently providing treatment should report all events in NHSN, regardless of permanent or temporary patient status.

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Dialysis Event Surveillance Protocol

? Include transient patients: A patient was temporarily admitted for treatment at your facility for a short time at the time of the event (fewer than 30 days or 13 treatments) due to vacation, emergency, or other short-term displacement. A patient is transient from the time they receive treatment at the temporary facility to the first treatment at their home facility. For example: Patient has treatment at their home facility. The next treatment is done at a temporary facility and completed. If an event happens after treatment is done at the temporary facility the event will be attributed to the temporary facility and the patient will be considered a transient patient. If an event happens after they receive treatment at their home facility, then the event will be attributed to the home facility.

? Include peritoneal dialysis patients or transplant patients undergoing temporary hemodialysis ? Include outpatients with acute kidney injury (AKI): Patients with AKI are defined by the

following criteria: a. No diagnosis of "End Stage Renal Disease' or "ESRD" in the patient medical record, or

through the ESRD Medical Evidence Form (Form CMS-2728-U3 ), AND b. Physician-diagnosis of "Acute Kidney Injury" or "AKI" listed in the patient medical record

(e.g., nephrologist consult or referral form), AND c. No more than 6 months has passed since the patient-initiated outpatient hemodialysis.

Requirements: Participating facilities are required to report data according to this protocol, using the NHSN definitions described herein, to ensure data are uniformly reported across participating facilities. Report available data to NHSN within 30 to 60 days of the end of the month for which they were collected. If additional data become available after that period, users are expected to report the additional information retrospectively to ensure NHSN data are complete and accurate. This may involve reporting additional dialysis events and/or editing existing event records.

Event Definitions and Key Terms

Dialysis Event: Three types of dialysis events are reported by users: IV antimicrobial start; positive blood culture; and pus, redness, or increased swelling at the vascular access site. The following measures are also generated from the reported data: bloodstream infection (BSI), local access site infection (LASI), access-related bloodstream infection (ARBSI), and vascular access infection (VAI).

21-day rule: An event reporting rule which reduces reporting of events that are likely to be related to the same patient problem. The rule is that 21 or more days must exist between two dialysis events of the same type for the second occurrence to be reported as a separate dialysis event. If fewer than 21 days have passed since the last reported event of the same type, the subsequent event of the same type is NOT considered a new dialysis event and therefore, it is not reported. The 21-day rule applies across calendar months. Refer to each event definition for instructions on applying the 21 day by event type.

IV antimicrobial start: Report all starts of intravenous (IV) antibiotics or antifungals administered in an outpatient setting, regardless of the reason for administration (e.g., include IV antimicrobial starts unrelated to vascular access infection) and regardless of the duration of treatment. A start is defined as a single outpatient dose or first outpatient dose of a course. Do not report IV antiviral starts. Report outpatient starts that are continuations of inpatient antimicrobial treatment.

? Outpatient setting is any facility where the patient was not admitted. These facilities include but are not limited to doctors' offices, clinics, or dialysis facilities. The home administration can also be considered an outpatient setting when antibiotics are administered by a home health professional or by the patient themselves and the patient is still receiving dialysis treatment at an outpatient facility.

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